On the afternoon of the 4th January 2018 Mr Benjamin Kelbie (Ben) was found hanging in his cell at HMP Manchester. He was 32 years old. Ben was an unsentenced prisoner.
Prior to his moving to HMP Manchester, Ben had also spent time on remand at HMP Forest Bank. Ben had a history of mental health problems and had been prescribed antipsychotic medication previously. Although Ben did not have a history of substance misuse the toxicology results found psychoactive substances in his system at the time of his death. Ben had made it known to staff in the days and hours prior to his death that he feared for his safety and wanted to move from the wing. No such move ever took place. There was no suggestion Ben had any suicidal ideation prior to his death and no notes were found in his cell.
The family’s concerns were primarily the following;
How when, where and why Ben came by his death, and in what circumstances.
How were Mr Kelbie’s medical and mental health needs managed prior to his death.
Ben’s access to psychoactive substances and the effect they may have had on his state of mind (and control and management of the NPS’s by the prison).
The problems Ben was facing on the wing and the fear for his safety and what action staff took.
The case was heard before HM Senior Coroner Mr Nigel Meadows, assisted by a jury over the course of 6 days, concluding on the 22nd November 2021. The interested parties were the family, HMP Manchester, Greater Manchester Mental Health Trust (GMMH) and, following the final Pre-Inquest Review Hearing, the Coroner took the opinion that the scope should be widened to include HMP Forest Bank where Ben was held prior to transfer to HMP Manchester.
The inquest heard how at no stage had Ben received any mental health input during his time in HMP Forest Bank or HMP Manchester despite his history and medication a clear indication of the need for such assessment.
Ben had also reported to prison staff that he feared for his safety owing to threats on the wing. Prison staff began the process of trying to move Ben to an alternative wing the days leading up to his death but this was not achieved prior to the discovery of Ben.
During the afternoon of the 4th January whilst in his cell with another prisoner Ben suggested he would self-harm and took himself to the toilet area of the cell. The alarm was raised by his cell mate some time later. Resuscitation attempts were made by staff but Ben was sadly pronounced deceased at the scene.
Recording a conclusion of Misadventure in box (4) of the Record of Inquest, the Jury went on to find in box (3) that:
The deceased likely suffered from paranoid schizophrenia for which he was on Olanzapine for several years. He was remanded in custody at HMP Forest Bank on the 20th June 2017 where there was a failure to refer him to Mental Health Services. He was then transferred to HMP Manchester on the 23rd October 2017 where again there was another failure to refer him to Mental Health Services.
On the 3rd and 4th of January the deceased made a request to move cell, made several enquires about the status of this move and arrangements were in progress to make the move. On the 4th January at 15:35, the deceased was found in his cell B13. He was found hanging by a ligature made by a torn bed sheet from the window in the separate bathroom area. Attempts were made to resuscitate but he was confirmed dead at 15:58.
Following the conclusion of the Jury the Coroner found it necessary to issue a Paragraph 40 letter of concern to the Prison and Probation Ombudsmen over the quality of their investigation. Consideration was given to a Regulation 28 letter to GMMH and they were notified of such in open Court. However, this was kept under review owing to HM Senior Coroner Mr Meadows awaiting responses to similar R28 letters sent to GMMH and felt further repetition of such was unnecessary pending the responses to his previous letters of concern.
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